DATE OF LOSS __________________ TYPE OF LOSS __________________ DATE

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					                               POLICYHOLDER
DATE OF LOSS:
__________________
TYPE OF LOSS:
__________________



                               CLAIMS FORM
DATE FORM WAS
COMPLETED:
__________________


General Info:                  This is an evolving form. Fill it out and provide it to your adjuster on a weekly basis or as FORM 1—Property
                               frequently as necessary until your claim is resolved. Keep a copy for your files.
Policyholder:

__________________________     L O S S I N F O R M ATION
Claim Number:

__________________________     Insurance Company and Address:                          _____________________________________________
                               _____________________________________________
Policy Number:                                                               Total Square Feet of Structure (s):
                               _____________________________________________
__________________________
                                                                             _____________________________________________
                               Adjuster’s Name and Address:                    _____________________________________________
Property Address:              _____________________________________________
                                                                               Total Square Feet of Damage: (see Measurements on page 2)
__________________________     _____________________________________________
                                                                               _____________________________________________
__________________________     Who is your adjuster employed by:
                                                                               Per Square Foot Cost of Repair to Bring Property to PRE-
__________________________     ____Insurance Co. ____Independent Adjusting Co. EVENT Condition: (see Contractor’s Bid on page 3)
Current Mailing Address:
                                                                                       $____________________________________________
                               Name of Independent Co :_________________________
__________________________                                                             Per Square Foot Cost to Replace Property Using LIKE KIND
                               Adjuster’s Phone/Fax/Email:
                                                                             AND QUALITY: (see Contractor’s Bid on page 3)
__________________________     _____________________________________________
                                                                             $____________________________________________
                               _____________________________________________
Phone: ____________________
                                                                                       Is the Coverage (Policy Limits) Sufficient to Repair or Re-
                               Date of Adjusters Inspection's: (see log on page 2)
Cell:______________________                                                            place? (Circle One)                     YES             NO
                               _____________________________________________
Fax: ______________________    _____________________________________________ Who Set the Policy Limit? (Circle One)
Email: _____________________                                                                                          POLICYHOLDER            AGENT
                               Areas of Damage Inspected by Adjuster:
                               _____________________________________________ Is Your Agent an INDEPENDENT AGENT or a CAPTIVE
                               _____________________________________________ AGENT? _________________________________
                               _____________________________________________
                                                                                       (an independent agent sells a number of brands of insurance policies
Coverage Limits                _____________________________________________ but a captive agent can sell only one brand)
                               _____________________________________________
                               _____________________________________________
Building
$__________________            INSPECTION CHECK LIST (To be completed in presence of adjuster )
Contents
                               1.   Was structure inspected for safety? Note damage: 6.      Was crawl space, pier/beam, or foundation in-
$__________________
                                    ____________________________________                     spected? Note damage:
ALE                                                                                          ____________________________________
                               2.   Was electrical system inspected for safety? Note
$__________________
                                    damage:                                            7.    If water entered structure, how many inches from
Unattached Bldgs.                   ___________________________________                      floor was the water?
$__________________                                                                          ____________________________________
                               3.   Was HVAC system inspected? Note damage:
Debris Removal                      ____________________________________ 8.                  Is mold present on drywall or wood? ________ If
$__________________                                                                          so, ask adjuster to make appropriate repairs.
                               4.   Was plumbing inspected? Note damage:
Deductible                          ____________________________________ 9.                  Do you need temporary housing?_____
$__________________
                               5.   Was roof, chimney, attic and garage inspected?     10. Will your adjuster give you an advance to get
Other                               Note damage:                                             temporary housing or emergency repairs? If so,,
$__________________                 ____________________________________                     how much? __________________________
                                                                                                                  Page 2
     FORM 1—Property


Measurements of Damaged Areas

            Room Description:                 Measurement:        Damage:

1.                                      1.                   1.

2.                                      2.                   2.

3.                                      3.                   3.

4.                                      4.                   4.

5.                                      5.                   5.

6.                                      6.                   6.

7.                                      7.                   7.

8.                                      8.                   8.                        Was there food spoilage?
                                                                                       If so, be certain to include
9.                                      9.                   9.                        spoiled items in your claim.

                                                                                       Were trees destroyed?
                                                                                       Check your policy as there is
                                                                                       probably coverage for lost
MOLD GROWS ON WET                                                                      shrubs and trees.
BUILDING MATERIALS
AND CAN DEGRADE THE
STRUCTURAL INTEGRITY
OF A BUILDING!
Termites and mold love moist
wood, drywall and plywood. Re-                                              POLICYHOLDERS OF AMERICA
move and replace ALL wet                                                    15 Orange Street
wood and drywall immediately                                                Charleston, SC 29401
to avoid this problem!                                                      888-648-8823
                                                                            We’re a click away:
                                                                             www.policyholdersofamerica.org
                             Inspection Log
     Date        Inspector      Notes




                                                                            POA is a non-profit, consumer
                                                                            educational organization. We help
                                                                            policyholders receive the benefits for
                                                                            which they’ve paid. We are funded
                                                                                                                                                                             Page 3
  FORM 1—Property

CONTRACTORS POLICYHOLDER ASKED TO BID
Get at least two bids based on the EX-
                                                                  All Bids Must Be Done On SAME SCOPE OF WORK
ACT scope of work required. Insist that
                                                  Contractor Name:
these bids be BINDING for several
                                                  Contact Number:
months. And, ask for a BID, not an
ESTIMATE.                                         Bid total:                             Is bid binding? If so, for how long?

                                                  Date contractor can begin:
If architectural plans are needed, you
                                                  Estimated completion date:
may need to have the insurer agree to
                                                  References:
hire an architect.
                                                                                                                                            Many insurers PAY their
Usually, the policy allows a 20—21% fee           Contractor Name:
                                                                                                                                            “preferred contractors” for
for a GENERAL CONTRACTOR if                       Contact Number:
THREE or more trades are involved. For            Bid total:                             Is bid binding? If so, for how long?               ESTIMATES. These contractors
example, if a painter, carpenter, and             Date contractor can begin:
                                                                                                                                            may never have any intention
roofer is needed, three trades are in-            Estimated completion date:
volved and General Contractor is                  References:
                                                                                                                                            of doing the work so they
needed to oversee the entire project.
                                                                                                                                            LOWBALL their estimates. Why
                                                  Provide written bids to insurance company.
                                                                                                                                            do you think they are

                                                                                                                                            “PREFERRED INSURANCE
CONTRACTORS SENT OUT BY YOUR INSURANCE COMPANY                                                                                              CONTRACTORS”? Get your
Here’s where it can get squirrelly. The insurance company will attempt to lowball estimates so they can pay less for your claim.            own BIDS from qualified, local
More often than not, their estimates are woefully low and are done by contractors PAID to submit the estimate. Be certain
that YOUR contractors bid on an inclusive scope of work and if the insurance company-hired contractor operates on a differ-                 contractors ready, willing and
ent (or inadequate) scope of work, ask your contractors to put in writing why they feel other repairs are necessary.                        able to do the work! Also,
                                                 INSURANCE CONTRACTOR’S ESTIMATE                                                            because of scammers that
Contractor’s name:
                                                                                                                                            swoop down on victims after
Phone number:
                                                                                                                                            disasters, we recommend only
Estimate total:
                                                                                                                                            using local contractors with
Date construction to begin by this contractor?

Date construction to be completed by this contractor?                                                                                       roots in your community. I
References:




YOUR DUTIES AND THEIR DUTIES
An insurance policy is a contract                the adjuster to be specific about              law, lowball your claim, put unrea-
between two parties. You have the                what you can do to protect your                sonable requirements on you, or
duty to COOPERATE with the                       property. For example, can you,                otherwise gyp you out of the cover-
insurance company (that means be                 without jeopardizing coverage, rip-            age for which you’ve paid.
reasonably available, give reasonable out wet drywall to prevent mold? If
                                                                                                   Remember, be firm but respect-
access to your property and pro-                 so, store all materials you want to
                                                                                                ful. If it all goes to hell in a handbag,
vide documents that are available to discard in large plastic garbage bags
                                                                                                call Policyholders of America at
assist the adjuster). You also have  away from the property so the
                                                                                                888-648-8823 for help.
the duty to MITIGATE damage                      adjuster can inspect the items.
which means protect the property
                                                   The insurance company has a
from further damage. If water dam-
                                                 duty to fairly and in a timely manner
age has occurred, be certain to ask
                                                 adjust your claim. They cannot, by
                                                                                                                               Page 4
FORM 1—Property




  Sometimes, insurance
                                            List any and all documents that the adjuster has asked you to provide, check the
  adjusters have the guts to
                                            box next to the document (s) you provided and write the date that you provided
  ask policyholders to                      each document:
  produce personal financial

  information like tax

  returns. Most courts
                                      ______________________________________________________DATE_______________
  consider this an invasion

  of privacy because your
                                      ______________________________________________________DATE_______________
  personal tax returns have

  NOTHING to do with the
                                      ______________________________________________________DATE_______________
  adjustment of a claim.

  You are only required to
                                      ______________________________________________________DATE_______________
  produce information

  helpful in the adjustment           ______________________________________________________DATE_______________
  of a claim. If you have any

  questions, please feel free         ______________________________________________________DATE_______________
  to contact Policyholders of

  America at 888-648-                 ______________________________________________________DATE_______________
  8823 or by email:
  info@policyholdersofamerica.org     ______________________________________________________DATE_______________




                                    List ANY unresolved issue below:

                                    _____________________________________________________________________________
                                    _____________________________________________________________________________
                                    _____________________________________________________________________________
                                    _____________________________________________________________________________
                                    _____________________________________________________________________________
                                    _____________________________________________________________________________
                                  Policyholders of America: Empowering the Policyholder

                                  GRADE YOUR INSURANCE COMPANY:


POLICYHOLDERS                     Assign a grade (A for excellent, B for above average, C for average, D for below average and F
OF AMERICA                        for failed miserably) to each of the following:

15 Orange Street                  Time Period Covered: from ______________________ to ________________________
Charleston, SC 29401
888-648-8823                      Applied all coverages available to me in my policy ___________
We’re a click away:
                                  Promptly investigated claim ___________
 www.policyholdersofamerica.org
                                  Thoroughly investigated all aspects of my loss __________

POA is a non-profit,              Provided realistic payments to me so I could get the work done ___________
consumer educational
organization. We help             Provided payments for LIKE KIND AND QUALITY ____________
policyholders receive the
                                  Encouraged me to use the contractor (s) of my choice ___________
benefits for which they’ve
paid. We are funded               Provided prompt payments ____________
exclusively by other
policyholders who have            Provided Additional Living Expenses for living quarters comparable to my own home _______
had their own battles with
their own insurance               Was helpful, courteous and did not fight me every step of the way ___________
companies and won. We
are not promoters of              Did not play “musical adjusters” with me ___________
litigation; in fact, we help      Allowed me to honor MY duties under the policy including my duty to mitigate damages _____
policyholders avoid
litigation by helping them        Acted in good faith and dealt with my claim in a professional manner _______
resolve their own claims.
                                  Asked only for information necessary to adjust my claim ________
Join us. Free and full
memberships are                   Other comments:
available.                        ______________________________________________________________________

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